bestBETs

You are asked to see a 2-month-old boy who has been ill for 3 days. He has respiratory syncytial virus positive bronchiolitis and is needing 1.5 L/min oxygen by low flow. His capillary blood gas has pH 7.26 pCO2 9.9 kPa pO2 4.5 kPa and base excess −5.0. His respiratory rate is 60 and increasing. The family has been told he may need moving to 40 miles to the regional paediatric intensive care unit (PICU). They are worried and angry, not least because his sister is delivering a baby upstairs. You wonder whether starting continuous positive airway pressure (CPAP) will reduce the need for ventilation and help keep them together.

As the paediatric registrar in clinic, you see a child with cystic fibrosis (CF). Her mother mentions reading about newer treatments available to help improve lung function and mucus clearance. You have heard of inhaled mannitol being used in this context and wonder how effective it is and how it compares to the established treatments.

A 3-year-old boy was seen in the community paediatric clinic for follow up of his Duchenne muscular dystrophy (DMD). There have been recent discussions about starting him on steroids. His parents would like to know if treatment with glucocorticoid corticosteroids (GCs) has been shown to prolong ambulation and the best age to start steroids. They also want to know if steroids reduce the complications of DMD and if the side effects of long-term steroids are acceptable.

A 9-year-old boy with a brain tumour attends my outpatient clinic for review. His current most disabling symptom is fatigue. His parents have done a Google search and found that methylphenidate can be used to treat fatigue in adults. They ask my opinion as to whether this would be an option for their son. What should I advise?

A 50-year-old man attends the emergency department with a history of cough, shortness of breath and purulent sputum production. He is hypoxic and shocked. He requires intubation and ventilation, and his post-intubation chest X-ray is consistent with bronchopneumonia. Following appropriate fluid resuscitation, he remains hypotensive and norepinephrine is commenced. Despite rapidly escalating norepinephrine, additional fluids and corticosteroids (for their catecholamine sparing effect), he remains shocked. A bedside transthoracic echocardiogram demonstrates left ventricular dysfunction which you feel may be attributed to septic myocardial depression. You wonder whether he might benefit from the addition of levosimendan.

A 53-year-old unrestrained driver who has been involved in a head-on collision arrives at the emergency department. He is immobilised on a spinal board and is wearing a semirigid cervical collar. As he has had opiate analgesia and might have had a head injury you are worried about the risk of vomiting (and subsequent aspiration of gastric contents). A junior member of the team asks whether antiemetic agents could be used prophylactically in all trauma patients, in order to limit the risk of vomiting. Interested in the result you set them the task of researching current literature and returning later in the week with the answer.

A 54-year-old man attends the emergency department complaining of a rapidly progressive pain and swelling in his right arm. He is mildly tachypnoeic and tachycardic. His arm is very tender and painful even at rest but is only slightly erythematous. He can move his hand, wrist and elbow with complete range of motion. You suspect a necrotising fasciitis. You wonder whether an ultrasound of the soft tissue night help to differentiate between cellulitis and a necrotising fasciitis.

A one-year-old girl presents to your Emergency Department with palpitations. The ECG recording is consistent with supraventricular tachycardia. You attempt to gain venous access multiple times but are unsuccessful. You wonder if the intraosseous delivery of adenosine is as effective as the intravenous one in terminating the arrhythmia

A 55-year-old woman attends the Emergency Department following a fall, during which she sustained an injury to her left shoulder. She complains of pain and is unable to abduct her arm to more than 90 degrees. An x-ray shows no fracture or dislocation and you suspect a rotator cuff injury. You know that MR imaging is a reliable method of confirming this type of injuries but also that it is expensive and time-consuming.<br><br>You wonder if ultrasound is as an accurate imaging modality at confirming a rotator cuff injury.

A 6 year old boy has been brought into the paediatric emergency department after an anaphylactic reaction to granary bread. After appropriate treatment the child's symptoms resolve. You wonder whether discharging with steroids will prevent a biphasic reaction?

A 19-year-old male is brought via EMS to the emergency department for seizure like activity, agitation, and anxiety after reported ingestion of multiple Monster Energy Drinks. Following a negative urine drugs of abuse screen you question whether his symptoms could be caused from toxicity from energy drink use?

A 6 year old boy was admitted for 60% full thickness body surface area burns. His stay in pediatric intensive care unit (PICU) was complicated with recurrent episodes of sepsis hampering the progress of enteral nutrition. The team wondered if beta-blockers can be used in this patient to reduce his hypermetabolic state.

You are a junior doctor in the neonatal intensive care unit. A preterm neonate has a loud murmur with bounding femoral pulse. Echocardiogram shows a haemodynamically significant patent ductus arteriosus. He is ventilated, but is otherwise well and has been tolerating full enteral feeds for a few days. A decision is made to commence intravenous Ibuprofen. You wonder whether oral Ibuprofen could be used and whether this would be as safe and efficacious as the intravenous route.

A multi disciplinary team working with diabetic and non diabetic patients who have had a lower limb amputation. A challenging area for the team is whether the diabetic patients can mobilise/weightbear after a partial foot resection. Situations have arisen in the past where consultant teams have had opposing views over the weightbearing status of the patient; non weight bearing or partial weight bearing with appropriate footwear.